Oregon's Patient Safety Commission is an independent agency with a mission to reduce patient harm. The agency created a voluntary, confidential reporting system for adverse events. Hospitals began reporting data in 2006, and the program is now being expanded to include nursing homes, ambulatory surgery centers, and retail pharmacies.
Commission administrator Jim Dameron says that "Oregon's voluntary reporting program isn't so much a surveillance tool as a quality improvement tool." For example, since hospitals reported so many cases of retained objects (such as sponges or guide wires left inside of patients after surgery), the Commission convened an expert group to offer recommendations for reducing risk. In another effort, the Commission documented the variation among hospitals in use of colored wrist bands to signal patients' particular needs and worked with the hospital association to champion clear and consistent standards.
The Commission also prepares bulletins to alert hospitals and other facilities about emerging safety issues and disseminates "pearls," or tips for improving safety and preventing errors. For example, Pearl #2 suggests having a one-page "Ticket to Ride" form accompany patients when they leave their hospital unit to identify their allergies, risk of falling, and special needs.
The Commission has been successful in signing up health care organizations; 54 of the state's 57 hospitals now report data. Dameron admits that voluntary reporting is hard to implement since it requires making the patient safety case one facility at a time. Still, Dameron says, "we have to pay a great deal of attention to our reporting partners. If we don't add value they won't play." Over time, the number of adverse events being reported is slowly increasing, which officials attribute to increased trust and acceptance of reporting, rather than an actual increase in adverse events. As a result, Dameron advocates maintaining the voluntary nature of this reporting effort, even though he suspects the program continues to suffer from some underreporting.
The Commission also brings together health care stakeholders to reach evidence-based consensus on patient safety issues. For example, in early 2007 it convened an expert panel on health facility acquired–infections. The panel developed agreements on how best to introduce a statewide mandatory reporting system for such infections (to begin in 2009). Recently, the Commission began a collaboration involving hospitals, nursing homes, and home health organizations to create guidelines aimed at reducing the risk of patients developing pressure ulcers.
The Commission is fully supported by fees from hospitals, nursing homes, ambulatory care centers, and pharmacies. Its annual budget is approximately $500,000.
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References
[1] L. Kohn, J. Corrigan, and M. Donaldson, To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 1999.
[2] Ibid.
[3] In 2006, the Pennsylvania Health Care Cost Containment Commission released a public report of hospital-acquired infection rates, with hospital-specific data.
[4] A "serious event" is defined as an event, occurrence, or current situation involving the clinical care of a patient at a medical facility that results in death, or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. An "incident" is defined as an event, occurrence, or current situation involving the clinical care of a patient in a medical facility, which could have injured the patient, but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient.
[5] Utah bill SB 41 states a provider's apology is inadmissible as evidence in a medical malpractice lawsuit.